Review

Cardio-obstetrics: Recognizing and managing cardiovascular complications of pregnancy

Kayle S. Shapero, MD, PhD, Nihar R. Desai, MD, MPH, Robert W. Elder, MD, Heather S. Lipkind, MD, Josephine C. Chou, MD, MS and Erica S. Spatz, MD, MHS
Cleveland Clinic Journal of Medicine January 2020, 87 (1) 43-52; DOI: https://doi.org/10.3949/ccjm.87a.18137

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Tables

  • TABLE 1

    Physiologic changes of pregnancy

    Arterial compliance increases throughout pregnancy
    Cardiac output begins to increase by 5 weeks and plateaus at 20 weeks
    Heart rate increases throughout pregnancy
    Systolic blood pressure increases at 20 weeks
    Systemic vascular resistance decreases early on, continues to decrease, and plateaus toward the end of pregnancy
    Stroke volume peaks at 24 weeks
    Relative anemia: Red blood cell mass increases but relatively less than plasma volume, which expands by 10% to 15% by 6–12 weeks
    During labor: Cardiac output increases 15% to 50% with contractions, and circulating volume increases
  • TABLE 2

    The Cardiac Disease in Pregnancy (CARPREG II) modified risk score

    PredictorPoints
    Prior cardiac events or arrhythmias3
    Baseline New York Heart Association functional class II or III heart failure or cyanosis3
    Mechanical valve3
    Ventricular systolic dysfunction2
    High-risk left-sided valve disease or left ventricular outflow obstruction2
    Pulmonary hypertension2
    Coronary artery disease2
    High-risk aortopathy2
    No prior cardiac intervention1
    Late pregnancy assessment1
    Total pointsRisk
    0–1  5%
    210%
    315%
    422%
    > 441%

    • Data from reference 62.

  • TABLE 3

    The Pregnancy in Women With a Congenital Heart Defect (ZAHARA) risk score

    PredictorPoints
    History of arrhythmias1.5
    Cardiac medication before pregnancy1.5
    New York Heart Association functional class before pregnancy ≥ II0.75
    Left heart obstruction (peak gradient > 30 mm Hg, or aortic valve area < 1.0 cm2)2.5
    Systemic aortic valve regurgitation (moderate or severe)0.75
    Mechanical heart prosthesis4.25
    Cyanotic heart disease (corrected or uncorrected)1.0
    Total pointsRisk
    0–0.5  2.9%
    0.51–1.50  7.5%
    1.51–2.5017.5%
    2.51–3.5043.1%
    > 3.5070.0%

    • Data from reference 63.

  • TABLE 4

    World Health Organization classes of pregnancy risk

    Class 1: Risk is considered equivalent to that in the general population
    Uncomplicated, small, or mild pulmonary stenosis, patent ductus arteriosus, mitral valve prolapse
    Repaired simple lesions, eg, atrial septal defect, ventricular septal defect, patent ductus arteriosus, total anomalous pulmonary vein drainage
    Isolated premature ventricular beats and atrial ectopic beats
    Class 2: Small increased risk of morbidity and death
    Unoperated atrial septal defect
    Repaired tetralogy of Fallot
    Most arrhythmias
    Class 2 or 3: Moderate increased risk of morbidity and death, depending on the patient
    Mild left ventricular impairment
    Hypertrophic cardiomyopathy
    Native or tissue valvular heart disease (not including class IV valvular disease)
    Marfan syndrome without aortic dilation
    Heart transplant
    Class 3: Significantly increased risk of morbidity and death
    Mechanical valves
    Systemic right ventricle (ie, repaired congenital lesions)
    Cyanotic heart disease
    Post-Fontan operation
    Complex congenital heart disease
    Class 4: Pregnancy contraindicated
    Pulmonary hypertension
    Severe systemic ventricular dysfunction (left ventricular ejection fraction < 30%)
    Severe left heart obstruction
    Marfan syndrome with dilated aorta (> 40 mm)
    Previous peripartum cardiomyopathy with residual impaired left ventricular function

    • Adapted from information in reference 33.

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